HomeMy Public PortalAbout6042 CAMELLIA AVE_Sewer__ WORMS'COMPENSATION DKIARATION
I hereby affirm'that'I have a certificate df consent to self
Insure,,K d certificate bf Worrs'keComperpau
tlgn Insuran , or 76A64M
a.`lkttfied copy thereof(Sbc. 3800, Lab C.) CZ 8M(REV."II APPLICATION FOR PERMIT
~Policy No._Company (as
❑ certified copy Is h"by fumiahed. SEWER - SEWAGE DISPOSAL
❑ Cenlfl*d copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL INpitCONNECTION DATA
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE STATION DEPTH
(This section need not be completed if the work Involved by theLoc�urY P I MANaIotFRFt UPPER
pa,rmlt Is for one hundred dollars (;100)or leas.)
FROM
I certify that In the performance of the work for which this �. TNEARESTYPE rTON KL TO P.L,
Y, CURB P.L MIL TO P.L
permit Is issued, I shall not ampI pry person rn arty manner P.c No.
so as to become subject to the Worker'Compensation Laws. OWNER ��j ��/CIAVd5/+ s CO.LW NO NQ
``(AA J � /L J TRUN IK PB MIT NO. ROAD PBWJT NQ.
Date Applicant ADO_
NOTICE TO APPLICANT: If, after making this Gatrtlflcate of Cn TEC_NO. �� � wArvra [AEEMBJT RECORD.irtsrR No. DATE
Exemptlorr, you should become at�blect to ti» Workers' UE—
Compensation proYlsrons of the Labor cgde, you must fbrthwlth DPSC.RVTK N LOT No. HWY.ORS WMA NG
comply with such provisions or this permit &hall be deemed
revoked. SLOOE TRACT STATE ENION)4C'f AMM
.
ISUMNO.OF N DGSPERMIT NO.
CONTRACTORS DECLARATION , yof LOT OF Now ON LOT
I herf�y affirm that I am llcer"d under provisions of Chapter _
9.(commencing with Section 7000) of Division 3 of the Bust- &U CHARM
nests and Profenlons Code, and my license Is in full force and
CONTRACTOR ODN NK71ON CHARGE H
License Number Llc.Class Alms O
CanlraCtor Date aTY TEL.No. NO. GROUP MAP PROCESS®BY V
z
STATE LIC ✓, F I / O
❑ I am•ximpt under Sec. of the LA Co. NO. CLASSV 0
Plumbing Code and/or Sec. of the NO. D6CR1 OF WORK EEE FINAL VALIDATION d
HHOUEE��CONI�ECTI NG TO DATE
B. 8 P. Code far the following reason AEtaC,
1 OR A
PITS Afi &DRAINED ETNA
Date HOUSE SEWER CONIIECTW TO BY
Signature CONNECT ADDfnCNAl BLDG.
OWNER-MLDER DECLARATION woRx To Hous SEWER
OVSWLOW SEEPAGE PIT
I hereby affirm that I am exempt from the Contrpotor's License EcrN. MAtaplC
Law for the following reasorr(Secton 7031.5, Bulsnass and PrREPAIR OR ABANDON HOUSE ' � ��
Pro,-
famlons Code): ORDAPOS,LSYSTEM 1 ITEM
❑ I,as owner of the property,cr my•mployasts with wages as
their sole comperactlon, will db the work 8nd the structure TOTAL 27 -50
Is hot Intended or offered for sale (Sectldrr 70.4, "In¢ss 27.50
nd Profestlons Code). OWNER'S • Permit $ CHECK
Xll
aes owner of the property,am exclusively contracting with AUTHORIZATION TOTAL PEE (HAWS ■0Insed contracton to construct the project (Sectlon 7044, 1 HAVE AT TM IS DATE A CONTRACT TF! HEREIN NAhy E)CONTRACTOR TO
BI.Iness and Profanloha Code). CONIN110 THE ABOVE R]EB E?aSTlN6 DWE31&JO TO THE PuKic:s5YAR
CONSTRUCTION LENDING AGENCY 1 10/ 5/89
1 hereby affirm that there Is a construction lendlrig agency 54GtJED i15 OF ' 1 loop the performance of the work for which this permit Is 6M 1 AM11440
Issued (Sec. 3097, Clv. C} owNE�s
ADDRt5;5
Lenders Name
Landers Address
I certify that I have rood this application End state that the
above Information Is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hareby author a representatives of this County to enter
u t v Honed property for Inapoctlon purposes.
Sig ea Date SM MVGRU FOR EMANAYORY LANGUA04 -